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Get Trillium Prior Authorization Form

E the most important components needed for your request to be processed: 1. Please print clearly 2. Complete all boxes marked with an * if not completed, request will be returned. 3. Attach any clinical notes, lab results, imaging results, etc., to support your request. There are three non * areas that are useful to the Health Plan in understanding your intent: 1. Requires (2nd Health Plan name) PA also? If that Plan is one we also manage, mark this box. It is helpful to enter that Plan I.

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